Suspensory Ligament Research Articles

Comparison of two advanced bipolar tissue sealer/dividers for laparoscopic ovariectomy in dogs: articulating enseal G2 versus Ligasure Maryland device

BackgroundAdvanced bipolar tissue sealer/dividers provide the most reliable and efficient means of tissue dissection and blood vessel sealing in laparoscopic surgery and the techniques are continuously improved. In veterinary practice, cost-effectiveness is of major impact, leading to re-use of instruments designed and sold for single use. Two high-end devices were evaluated and compared in a highly standardized laparoscopic ovariectomy procedure in dogs: The new generation Ligasure Maryland Sealer/Divider (LMSD) with improved atraumatic curved jaw shape for delicate tissue handling and dissection and non-stick nanocoating, and the new-generation Articulating Enseal G2 (AENG2) with several proclaimed features improving surgical performance, including articulation of the forceps tip; improved tissue compression during sealing; unique offset electrode configuration; and specific nanoparticle coating minimizing thermal spread and tissue sticking. Twenty-one client-owned dogs admitted for elective laparoscopic ovariectomy were randomly assigned to one of two groups: ovariectomy using AENG2 on the left ovary and LMSD in the right ovary or vice-versa. Procedural video recordings were used to assess ovarian ligament fat score, smoke formation, occurrence of bleeding, and excision duration. Excised tissues were examined histopathologically and collateral thermal damage was scored in three anatomic zones: suspensory ligament, vascular pedicle, and uterine junction. Tissue sealers were used repeatedly following standardized cleaning protocol with instrument washing machine and ethylene oxide gas sterilization and the number of uses until device failure was recorded.ResultsExcision times were significantly increased for AENG2 (median 01:35 min) compared to LMSD (median 01:00 min). Minor hemorrhage from incomplete sealing occurred in 3 sites in 2 patients (2x AENG2, 1x LMSD) and was not significantly different between groups. Smoke production as scored on videos and thermal tissue damage scores on histopathology also did not differ between AENG2 and LMSD. Both vessel sealers could be re-used repeatedly.ConclusionAENG2 provides a good alternative to LMSD in laparoscopic ovariectomy, with only minor differences in measured variables. Subjectively, the articulating feature of AENG2 did not improve surgical performance in laparoscopic ovariectomy and the use of LMSD appeared more straight-forward for this specific procedure. However, differences in operating these devices may be subject to personal preference.

The plantar proximal cortex of the third metatarsal bone shows raised longitudinal ridges at the suspensory ligament enthesis in normal equine isolated limbs - a radiographic, computed tomography, and MRI study.

Knowledge of normal radiographic appearance is essential to avoid misinterpretation of radiographs. This study aimed to assess the computed tomographic (CT) appearance of the plantar surface of the proximal metatarsus and evaluate the influence of the radiographic angle on the trabecular/cortical interface of the proximal plantar metatarsal cortex on lateromedial and slightly oblique radiographs. Eight hindlimbs were collected from six horses with no known history of lameness and euthanized for reasons unrelated to the study. Limbs underwent computed tomographic (CT) and radiographic examination (dorsoplantar, lateromedial, and slightly oblique radiographic views obtained by angling the beam dorsally and plantarly from the plane used for the lateromedial projection). Standing magnetic resonance (MR) imaging and computed tomography (CT) were used to confirm normalcy. Images were compared side-by-side by two experienced readers. Limbs were normal at MR imaging. Longitudinal linear ridges were present on the proximal plantar metatarsal surface in all limbs (1-2 sagittal ridges and 1 ridge located at the medial or lateral margin of the suspensory ligament). Longitudinal ridges were positioned facing an adipose-muscular bundle of the suspensory ligament on CT images and were visible as linearly increased opacities on dorsoplantar radiographs. The delineation of the trabecular/cortical interface of the proximal metatarsus changed with radiographic projection and was the sharpest on the plantaro 85° lateral to the dorsomedial oblique view. The proximal third metatarsal bone shows individual morphological variations, with longitudinal linear ridges that alter the bone homogeneity on dorsoplantar radiographs. An oblique plantaro 85° lateral to the dorsomedial view is suggested to better assess the presence of subcortical sclerosis when proximal suspensory enthesopathy is suspected.

Penile suspensory ligament release: efficacy and complications

Penile suspensory ligament release: efficacy and complications

Suspension of the penis – dissection, anatomical description and highlighting of anatomical risks in sectioning the suspensory ligaments

BackgroundThe suspension of the penis is provided by two ligaments: fundiform and suspensory. These ligaments are sectioned during some augmentative surgical procedures. The structure, the relations and the variability of these ligaments have been demonstrated. The penile neurovascular bundle and its relationships have also been emphasized. A clear knowledge of these details should ensure a reduction of the risk of surgical injury during augmentation procedures.ResultsWe dissected the ligaments providing the suspension of the penis in 7 formalized corpses. We identified, for each of the ligaments, the origin, the insertion and the relations. The dissection pieces were photographed and the images obtained were discussed upon. We described the variability of the anatomical distribution and highlighted the relations with the vascular and nervous structures for each of these ligaments. The anatomical variability of the fascia and the relations with the base of the penis were also emphasized. For the suspensory ligament, we identified three groups of fibers through which it is attached to the penile body.ConclusionsThe dissections were conducted in layers, corresponding to the operative steps for the penile augmentation procedures. We believe that our study highlights the anatomical basis necessary to safely perform these surgeries. The study contributes to the description of the anatomical variability of the ligaments and logically presents details that contribute to preventing most surgical incidents.

Equine allogeneic tenogenic primed mesenchymal stem cells: A clinical field study in horses suffering from naturally occurring superficial digital flexor tendon and suspensory ligament injuries.

Mesenchymal stem cells are an innovative therapeutic for various equine orthopaedic diseases, including soft tissue injuries. To evaluate the safety and efficacy of tenogenic primed equine allogeneic peripheral blood-derived mesenchymal stem cells (tpMSCs) in horses with naturally occurring superficial digital flexor tendon (SDFT) and suspensory ligament (SL) injuries. Multicentre, blinded, randomised, placebo-controlled clinical trial. One hundred client-owned horses with SDFT and SL injuries were randomised to receive an intralesional tpMSC (66) or saline (34) injection. Clinical and ultrasonographic evaluation was performed before treatment and on Days 56 ± 3 and 112 ± 3 after treatment. Long-term data on re-injury was collected up to 2 years after treatment. Significantly more tpMSC-treated horses achieved improvement in fibre alignment score (FAS) (100% vs. 54.5%, p < 0.001) and echogenicity (97.0% vs. 57.6%, p < 0.001) on Day 112 ± 3, and their lesion size decreased significantly (-27.6 ± 25.91 vs. -4.6 ± 26.64 mm2, p < 0.001) compared to the placebo group. A FAS = 0 was achieved in 65% of tpMSC-treated horses, as compared to 9% of placebo-treated horses at Day 112 ± 3. The attending veterinarians reported no re-injury in 41 of 53 tpMSC and in 2 of 26 saline-treated horses available for long-term follow-up (p < 0.001). As this study consisted of client-owned horses, no samples for histology were collected. Long-term follow-up was only available for a subset of enrolled horses. The intralesional administration of tpMSCs was safe and improved the quality of healing and long-term outcomes in sports horses with naturally occurring SDFT and suspensory injuries.

Low-Field Magnetic Resonance Imaging Findings of the Fetlock Region of Nonracehorses

Low-field, magnetic resonance imaging (MRI) is an advanced imaging modality widely used to diagnose distal limb pathology in horses, but there are limited data regarding lesion distribution within the metacarpo/metatarsophalangeal joint (MCP/MTPJ) region in lame nonracehorses. The aim of this study was to describe the low-field MRI findings and lesion distribution in nonracehorses with MCP/MTPJ region pain. Clinical records from horses undergoing MRI of the MCP/MTPJ region between July 2016 and March 2023 were reviewed. Horses were included if pain causing lameness was localized to this region and conventional imaging failed to provide a definitive diagnosis. Eighty-four horses met the inclusion criteria. Soft tissues were affected in 76 (90.5%) horses, with suspensory ligament branch injuries being the most frequent (60.7%) soft tissue pathology identified. Osseous pathology was diagnosed in 51 horses. The subchondral bone (SCB) of the distal third metacarpal/metatarsal bone (MC3/MT3) was the osseous structure most frequently affected (40.5%), with 79.4% of these horses having lesions on the dorsal aspect of the bone. Osteoarthritis was present in 48 (57.1%) horses. The main limitations of the study were the lack of a standardized diagnostic analgesia pattern due to varying veterinary surgeon involvement, and the absence of bilateral magnetic resonance (MR) sequences in all limbs. MRI is a useful diagnostic tool to assess soft tissue structures in the MCP/MTP region, especially in horses with thick skin, which may make ultrasonographic imaging unreliable.

High level sound transmission through cadaver human ears—On the influence of bone conduction and hearing protective devices

High level sound exposure can cause substantial injury to the auditory system, motivating efforts to predict and prevent this injury. Measurement techniques using acoustic manikins are effective for low and moderate sound levels, but nonlinear effects in the middle ear and alternate sound transmission pathways to the inner ear limit their utility at higher sound pressure levels. Here, we describe results from a series of measurements made in cadaveric human ears conducted in our laboratory over the last several years. We quantified sound transmission to the inner ear by measuring the difference in sound pressure level across the cochlear partition near the base of the cochlea, which drives basilar membrane motion. We describe measurements quantifying sound transmission through the human middle ear, which is limited by suspensory ligaments for sounds above approximately 130 dB SPL, resulting in nonlinear (harmonic) distortion of sounds in the cochlea at higher sound pressure levels. Similarly, we describe observations of sound transmission to the cochlea via bone conduction from vibratory transducers, as well as high level sound and impulse noise/blast exposures. The implications of these measurements for hearing loss predictions, effectiveness of hearing protective devices, and injury mechanisms are discussed.

Evaluation of Sexual Side Effects in Patients after Chemoradiation and Brachytherapy for Gynecologic Cancers Involving the Lower Vagina and Bulboclitoris

Radiation toxicity to the bulboclitoris has not been previously investigated. This retrospective cohort study aims to report sexual side effects of patients who underwent radiotherapy for tumors involving the lower vagina, periurethra, and bulboclitoris (BC). Patients treated between 2017- 2022 for gynecologic cancer involving the low vagina were included. The high-risk clinical target volume (HR-CTV), bladder, rectum, and urethra were contoured on patient imaging during initial treatment planning. The BC was retrospectively contoured using T2 MRI sequences fused to the pre-treatment and brachytherapy CT simulation. Superiorly, the BC was defined as inferior to the pubic symphysis and attached to the suspensory ligament of the clitoris. Laterally, the crura extend on either side of the corpus. Inferiorly, the vestibular bulbs flank the urethra and vagina on either side, extending posteriorly to mid-vagina. Dosimetric data for the BC, vaginal morbidity using the CTCAE 4.0 for vaginal stenosis, and pain scoring of the BC were obtained via chart review. Patients underwent external beam radiotherapy (IMRT) to the pelvis and bilateral inguinal region (45 Gy in 25 fractions) followed by High Dose Rate Ir-192 interstitial brachytherapy in 5 fractions for a total dose of 25 Gy (22.5 - 27.5 Gy). Patients had a median age of 65 years (49-73) with tumors located in the lower vagina, near the BC and urethra. At the time of brachytherapy, in order to cover the HR-CTV, interstitial brachytherapy needles were placed within the BC structure with 58% (33% - 77%) of total interstitial needles placed within the bulbs of the BC. The mean pre-treatment volume of the BC was 16.6 cc (11.9 - 20.9 cc) and at brachytherapy was 12.66 cc (7.3 - 22.1 cc) with Table 1 summarizing radiation doses. At a median follow up of 19.6 months, all patients had a complete local response, with one patient deceased of metastatic disease. In the acute period, all patients reported severe pain in the clitoral glans region and dysuria that completely resolved after 2 years. Grade 1-2 vaginal stenosis occurred in all patients despite vaginal dilator usage. One patient reported decreased clitoral sensitivity and inability to achieve clitoral-mediated orgasm 5 months after radiotherapy. This study demonstrates that the BC receives a significant radiation dose during vaginal brachytherapy treatment which can cause clitoral pain and dysfunction. Further studies are needed to evaluate the dose response of the BC as well as explore methods to spare the organ during radiation therapy in order to minimize toxicity and preserve sexual function.

Findings consistent with equine proximal suspensory desmitis can be reliably detected using computed tomography and differ between affected horses and controls.

The objective of this retrospective, observational, controlled study was to evaluate bone and soft tissue window CT images of the proximoplantar metatarsus III region in twenty horses with pain localized to the proximal suspensory ligament (PSL) and 20 horses with findings nonrelated to tarsal pain. All horses underwent CT and radiographic examination. Images were reviewed by three independent observers who graded the severity and localization of findings. Bone-related categories as well as soft tissue-related categories were evaluated. For the comparison of imaging findings in horses with and without proximal suspensory desmitis (PSD), mixed linear regression was performed. The intraclass correlation coefficient (ICC) was calculated to assess intraobserver agreement, and kappa statistics were employed to evaluate interobserver agreement. CT examination identified significantly more abnormalities in the diseased group. The scores for osseous exostosis (p=.015) and PSL enlargement (p=.004) were notably higher in PSD horses compared to controls. Intraobserver agreement was overall high (ICC .82-1.0), and interobserver agreement was substantial for the detection of mineralization (kappa=.61) and moderate for sclerosis (kappa=.43), exostosis (kappa=.43), and PSL enlargement (kappa=.48/.51). Measurements in the soft tissue window were significantly smaller than those in the bone window. Findings concurrent with PSD including osseous proliferation and sclerosis as well as soft tissue enlargement, mineralization, and avulsion can be reliably detected using CT. Findings from the current study supported the use of CT for evaluating horses with suspected PSD where high-field MRI is not available.

Genetic architecture and polygenic risk score prediction of degenerative suspensory ligament desmitis (DSLD) in the Peruvian Horse.

Introduction: Spontaneous rupture of tendons and ligaments is common in several species including humans. In horses, degenerative suspensory ligament desmitis (DSLD) is an important acquired idiopathic disease of a major energy-storing tendon-like structure. DSLD risk is increased in several breeds, including the Peruvian Horse. Affected horses have often been used for breeding before the disease is apparent. Breed predisposition suggests a substantial genetic contribution, but heritability and genetic architecture of DSLD have not been determined. Methods: To identify genomic regions associated with DSLD, we recruited a reference population of 183 Peruvian Horses, phenotyped as DSLD cases or controls, and undertook a genome-wide association study (GWAS), a regional window variance analysis using local genomic partitioning, a signatures of selection (SOS) analysis, and polygenic risk score (PRS) prediction of DSLD risk. We also estimated trait heritability from pedigrees. Results: Heritability was estimated in a population of 1,927 Peruvian horses at 0.22 ± 0.08. After establishing a permutation-based threshold for genome-wide significance, 151 DSLD risk single nucleotide polymorphisms (SNPs) were identified by GWAS. Multiple regions of enriched local heritability were identified across the genome, with strong enrichment signals on chromosomes 1, 2, 6, 10, 13, 16, 18, 22, and the X chromosome. With SOS analysis, there were 66 genes with a selection signature in DSLD cases that was not present in the control group that included the TGFB3 gene. Pathways enriched in DSLD cases included proteoglycan metabolism, extracellular matrix homeostasis, and signal transduction pathways that included the hedgehog signaling pathway. The best PRS predictive performance was obtained when we fitted 1% of top SNPs using a Bayesian Ridge Regression model which achieved the highest mean of R2 on both the probit and logit liability scales, indicating a strong predictive performance. Discussion: We conclude that within-breed GWAS of DSLD in the Peruvian Horse has further confirmed that moderate heritability and a polygenic architecture underlies the trait and identified multiple DSLD SNP associations in novel tendinopathy candidate genes influencing disease risk. Pathways enriched with DSLD risk variants include ones that influence glycosaminoglycan metabolism, extracellular matrix homeostasis, signal transduction pathways.

Multimodal imaging and surgical repair of a dorsal‐oblique plane, proximal third metacarpal fracture and the diagnostic challenge of radiographic visualisation

SummaryA 10‐year‐old Connemara mare presented with persistent 3/5 (AAEP) right forelimb lameness following a traumatic incident whilst hunting, which was localised to the proximal metacarpal and distal carpal regions with diagnostic anaesthesia. Radiography revealed non‐specific moderately increased mineral opacity at the proximomedial margin of the third metacarpus, dorsal to the enthesis of the proximal suspensory ligament. However, subsequent computed tomography (CT) performed under general anaesthesia, identified an incomplete, dorsal ‐ obliquely orientated third metacarpal fracture arising from the interosseous space between the third and second metacarpi, also involving the carpometacarpal joint. Using CT guidance, internal surgical fixation was performed under the same anaesthetic episode and resulted in a shortened post‐operative recovery period with a successful return to previous athletic function. Surgical fixation can be performed using cross‐sectional imaging guidance to optimise recovery and facilitate a positive outcome.

Ultrasonographic description of tendons and ligaments at the palmar (plantar) aspect of the distal limb in the one humped camel (Camelus dromedarius).

To provide complete anatomical and ultrasonographic description of tendons and ligaments at the palmar (plantar) aspect of the cannon and phalangeal regions of the one-humped camel. Forty-two (21 fore and 21 hind) clinically normal camel cadavers' limbs disarticulated at the carpal and tarsal joints and three clinically normal mature camels were included in the study. Six cadaver limbs (three fore and three hind) were dissected, and another six limbs specimens (three fore and three hind) were frozen at -20° for 1 week then sectioned transversely with an electric band saw at different distances distal to the carpometacarpal and tarsometatarsal joints. The ultrasonographic study was carried out on the live camels and 30 cadaveric limbs. The shape, echogenicity and measurements (thickness, width and cross-sectional area) of superficial digital flexor tendon (SDFT), deep digital flexor tendon (DDFT), suspensory ligament (SL), and sesamoidean ligaments were recorded and the differences in values between live animals and cadaveric specimens were statistically analysed. The shape and echogenicity of SDFT, DDFT, and SL, varied between proximal, middle, and distal thirds of the cannon bone and the phalangeal region. There was no significant difference between live animal and cadaveric specimens. This study provided complete description of tendons and ligaments at the palmar (plantar) aspect of the cannon and phalangeal region of the one humped camel. The data obtained serves as a reference guide for practicing veterinarians and for future studies on injury to ligaments and tendons of camel's distal extremity.

Racing performance of Thoroughbred racehorses with suspensory ligament branch desmitis treated with mesenchymal stem cells (2010-2019).

Suspensory ligament branch desmitis (SLBD) is a common injury in Thoroughbred racehorses. Orthobiologic treatment of these injuries is a relatively new approach, and there is limited information available on post injury racing performance in racehorses treated with mesenchymal stem cells (MSCs). To assess racing performance post injury in Thoroughbred racehorses with SLBD treated with MSCs. Retrospective case series. Medical records of racehorses with SLBD treated with MSCs from 2010 to 2019 were reviewed. All horses were treated with allogeneic stem cells injected locally at the time of diagnosis and subsequently received 3-4 treatments with autologous bone-marrow derived MSCs. Ultrasonographic and radiographic images were evaluated to determine the degree of suspensory branch injury and sesamoiditis of the associated proximal sesamoid bone. Race performance was assessed by career length, class of races, number of starts and earnings post injury. Race performance of horses that raced pre and post injury were compared. Of 69 treated horses, 71% (49/69) [95% CI: 59%-81%] raced post injury. Horses that had raced pre injury were more likely to race post injury (90% [18/20]) than horses that did not race pre injury (63% [31/49]; p = 0.03). Females were less likely to race post injury than males (52% [11/21] vs. 79% [38/49], respectively; p = 0.02). In the 18 horses that raced pre and post injury, the number of races, earnings and earnings per start were not significantly different pre and post injury. The average career length of all horses that raced post injury was 29.5 months. Retrospective study design and lack of controls. Treatment with MSCs resulted in a majority of Thoroughbred racehorses with SLBD racing post treatment. Racing pre injury and being male was positively associated with racing post injury.

Biometrics of the suspensory ligament of the thyroid and its correlation with the morphometry of the thyroid gland in cadavers of human fetuses

Introduction: Berry’s ligament (BL) is a known anatomical structure, which connects the thyroid gland to the tracheal wall, but its biometry has so far been little explored. Objective: In the present study, we sought to perform the BL biometry, correlating it with the morphometry of the thyroid gland. Material and method: Without the aid of optical instruments, the BL of 24 thyroid glands of human fetuses were dissected. With the gland in an anatomical position, the biometric data of the BL and the gland were taken. The data were treated statistically to establish the correlation between the length and height of the BL with the biometric data of the thyroid gland. Result: Significant correlations were found at the 5% level for the width of the thyroid gland and the weight of the gland, as well as for the length of the left lobe and the width of the right and left thyroid lobes, all in relation to the length of the LB and also the length in relation to the width of the gland and the isthmus of the thyroid gland. There was no significant correlation between the BL height and the morphometric findings of the right and left lobes and the isthmus of the thyroid gland. Conclusion: Knowledge of the anatomy of the BL is essential to prevent, in particular, injuries to the RLN, during thyroidectomy or parathyroidectomy.

Expression of genes with biomarker potential identified in skin from DSLD-affected horses increases with age.

Degenerative Suspensory Ligament Desmitis (DSLD) negatively impacts connective tissues in horses, which often leads to progressive chronic pain and lameness. DSLD has been shown to be a systemic disorder that affects multiple body systems, including tendons, sclerae, and the aorta. Currently, the diagnosis is confirmed by post mortem histological examination of a tendon or suspensory ligament. Histology reveals inappropriate accumulations of proteoglycans in the tendons and other tissues in DSLD-affected horses. Unfortunately, there is no reliable method to diagnose DSLD in living horses. Recently, bone morphogenetic protein 2 (BMP2) was identified in active DSLD lesions. In addition, recent data from RNA sequencing (RNA-seq) showed overexpression of numerous genes, among them BMP2, FOS and genes for keratins in DSLD skin biopsies-derived RNA. We hypothesized that some of these genes can be used as biomarkers for diagnosis of DSLD in a panel. Overexpression of some of them was verified in quantitative real time PCR. Immunohistochemistry and RNAscope in-situ hybridization (ISH) assays were used to determine the level of overexpression of specific genes in skin biopsies from control and DSLD-affected horses. The RNAscope ISH assay has shown to be more reliable and more specific that immunohistochemistry. ISH confirmed a significant increase in KRT83 and BMP-2 in hair follicles in DSLD cases, as well as abnormally high expression of FOS in the epidermis, especially in aging horses. Because statistically relevant specificity and sensitivity was documented only for FOS and BMP2, but not KRT83 we recommend the use of FOS and BMP2 panel to diagnose DSLD. We conclude that a panel of two markers from the studied group (BMP2 and FOS) can serve as an additional diagnostic tool for DSLD in living horses, especially in older animals. Further studies are necessary to confirm if this biomarker panel could be used as a prospective tool to identify DSLD in horses as they age.

Contrast administration via ultrasound-guided injection of the cranial tibial artery results in contrast enhancement of the soft tissues of the metatarsus in horses undergoing CT.

Delivery of mesenchymal stem cells (MSC) via intravascular techniques to treat diffuse and/or inaccessible soft tissue injuries has grown in popularity. The purpose of the current prospective, analytical pilot study was to utilize CT to validate this novel technique and provide additional evidence to support its use for injectate delivery to specific soft tissue structures. Of particular interest was the proximal suspensory ligament, which presents a challenging injection target. Six adult horses without lameness underwent CT of the distal hindlimbs. Scans were obtained prior to ultrasound-guided catheterization of the cranial tibial artery, in addition to early and delayed scans acquired following intra-arterial contrast administration. Region of interest analysis of the superficial and deep digital flexor tendons and suspensory ligament was used to assess contrast enhancement within these structures. Linear mixed models were used to determine statistical significance. Significant (P<0.05) mean contrast enhancement was seen in all postinjection time points in all soft tissue structures of interest. This indicates that ultrasound-guided injection of the cranial tibial artery results in perfusion of injectate throughout the distal hind limb, including the major soft tissue structures of the metatarsus. This provides further support for this technique as a method of MSC delivery to multifocal or inaccessible injury of these structures, including the proximal suspensory ligament.

Ectopic Spleen in the Pelvis: A Case Report

Ectopic spleen is a rare clinical condition characterized by splenic hypermobility caused by elongation or mal-development of the suspensory ligaments leading to the presence of spleen outside of its normal position. It is most commonly presented in children younger than 1 year and in females of childbearing age.A 34-year-old woman underwent magnetic resonance imaging (MRI) after suspicion of uterine fibroids. The patient only complained of a painless lower abdominal mass. MRI revealed the enlarged spleen in the pelvic area, measuring 17 × 4.6 cm, suspended by elongated, dilated, and tortuous pedicle in the absence of the spleen in its normal position. Multiple factors could be attributed to the development of an ectopic spleen. These include the following: (1) congenital anomalies in the development of the dorsal mesogastrium and the absence or malformation of the normal splenic suspensory ligaments, (2) acquired conditions such as splenomegaly and pregnancy. An ectopic spleen can present in a variety of ways clinically. It might pass unnoticed throughout life. However, ectopic spleen should be considered in the differential diagnosis of patients presented with an abdominal mass. Imaging modalities are used to make a final diagnosis. The treatment choice for an ectopic spleen is splenopexy. Splenectomy is only necessary in case of an infarction.

Стриктуры мочеиспускательного канала, как осложнение трансуретральной хирургии предстательной железы.

Introduction. The inclusion of antibiotic therapy into clinical practice in the second half of the 20th century radically changed the «etiological landscape» of urethral stricture disease. Against the background of a decrease in the proportion of inflammatory strictures, the introduction of new technologies, the spread of transurethral interventions in urology has led to an increase in the incidence of iatrogenic strictures. The purpose of this review is to systematize risk factors for urethral strictures after transurethral prostate surgery. Materials and methods. A search was made for the keywords «transurethral resection of the prostate», «urethral stricture», «iatrogenic urethral strictures», «urethral injuries» in the databases PubMed, eLibrary, Scopus, EMBASE, websites of professional associations. 58 publications were selected for review and analysis, 5 of which are domestic. Results. The influence of the following factors was analyzed: the method of energy supply, the type of energy, the method of removing prostatic tissue; instrument diameter and anatomical features of the patient; resection speed, operation time and volume of removed prostatic tissue; urinary tract infection; electrical damage; other risk factors for TURP. Conclusion. The proven factors include: the diameter of the instrument, operating times, urinary tract infection. Probable factors should be considered the anatomical features of the patient: «narrow urethra», a short penile suspensory ligament.

(130) Increasing Penile Length and Girth in Healthy Men Using a Novel Protocol: The P-Long Study

Abstract Introduction Various therapies have been utilized to increase penile length and girth, with some exhibiting significant adverse event profiles, including fillers, fat transfers, suspensory ligament ligation, and silicon augmentation. Our team sought to evaluate a novel combination therapy to enhance penile characteristics using platelet-rich plasma (PRP) as a source of autologous growth factors, penile traction for lengthening, a vacuum erection device for girth enhancement, and nitric oxide precursor supplements to augment penile vascular smooth muscle function. Objective To evaluate the safety and efficacy of combination therapy with PRP, traction, vacuum device, and nitric oxide boosting nutritional supplements to increase penile length, girth, and function in healthy men. Methods A prospective, non-randomized study was designed (NCT04231422) to evaluate the efficacy of combination therapy in healthy men aged 20-55 with baseline normal erectile function and no penile pathology. Penile length and girth measurements were obtained using at-home photography of an erect penis with maximal tumescence. Measurements were obtained at baseline and at monthly intervals x 6 months. PRP (a modified P-Shot ® Procedure) was administered in the right and left corpora under ultrasound guidance once a month for six months using PureSpin double spin system (60cc blood drawn). Centrifuge technical data show an average platelet recovery of 84% and an average concentration of 6.6 times that of the whole blood sample. Using this data, the injection of 10cc of PRP, assuming a starting platelet count of 250K/microliter, would contain approximately 1.65 billion platelets. Subjective erectile function was assessed with a 5 point Likert Scale. RestoreX traction device was utilized for 20 minutes, twice daily, and a Dr Joel Kaplan vacuum erection device was applied with 5-10 mmHg pressure x 12 minutes (1 min x 2, 5 min x 2). Oral nitric oxide boosting supplementation was with AFFIRM, consisting of 3 gm L-Citrulline and 1 gm beet extract. Results A total of 32 men have been enrolled, with 16 having complete data available for review. The 6-month mean increase in the size of the erect penis was 0.85 inches in length (95% CI: 0.75 to 0.94, p-value &amp;lt; 0.01) (range 0.5-1.44) with a linear increase in size. The 6-month mean increase in circumference was 0.47 inches (95% CI: 0.37 to 0.57, p-value &amp;lt;0.01) (range 0.2-0.75). Mean age was 32 and mean baseline erect penile length was 5.70 and girth was 5.25. All 16 participants reported better penile rigidity with erections. No adverse events were reported. Conclusions Results from a pilot study using a novel combination therapy (P-Long Protocol) in healthy men demonstrated increases in penile length, girth, and subjective rigidity improvement compared to baseline with no adverse effects. External validation is warranted. The P-Long Protocol does not require any synthetic injectables or foreign bodies. It does not preclude additional augmentation procedures. The slope of the growth curve indicates possible continued growth with additional treatments. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: BTL Inc.

(344) The Surgical Outcome of Buried Penis Surgery

Abstract Introduction Buried penis is a condition where the penis retracts and becomes hidden beneath the skin. It has a significant impact on quality of life of the patient and can present with a variety of symptom including lower urinary tract symptoms and erectile dysfunction. Whilst there are several causes, obesity is the most common in adults. Objective The aim of this study is to assess the variety of different operations performed with patient and surgeon satisfaction rates. Methods This is a retrospective study on patients with a buried penis operated on between 2010 and 2020. Data retrieved included presenting complaints, previous surgery, co-morbidities, surgical details and patient and surgeon satisfaction rates with cosmesis. Results A total of 141 patients were recruited with buried penis (median age 54, range 20-80). The presenting complaints were inability to void standing n = 30, erectile dysfunction n = 18, small penis n = 94. Aetiological factors included diabetes n=47, vascular disease n=62, penile cancer surgery n= 3 and BXO n= 13. The BMI was recorded in 44 patients (range 23-52) with 7 being morbidly obese (BMI &amp;gt;40). 47 patients had only a weight was recoded with a median of 114kg (range 68-169kgs). A total of 96 (68%) patients had had previous surgery prior to referral and in particular circumcision in 49 patients. The operations performed on the 141 patients were circumcision n=40, scrotoplasty n=35, V-Y plasty n=11, skin grafting n=34, suprapubic fat pad excision n=77, abdominoplasty n=25, malleable penile prosthesis n=7, inflatable prostheses n=7 and division of suspensory ligament n=24. The post-operative length of stay was median 3 days (range 0-52 days) but for abdominoplasty and grafting this was a median of 5 days (range 1-52 days). There were 27 complications (19%); infections (n=15), dehiscence (n=5), haematomas (n=2) The mean follow up was 506 days (range 0-4313 days) with a surgical satisfaction rate of 87% and patient satisfaction of 79%. Of note the highest dissatisfaction occurred in patients having circumcision or suprapubic fat pad removal. Conclusions Buried penis is a complex condition with patients likely requiring a combination of surgical techniques. Circumcision alone usually does not treat the problem and may make things worse. A prolonged hospital stay with significant wound complications may occur but the majority of patients are happy with the final outcome. Disclosure No